Acute myocardial infarction in association with coronary artery atherosclerosis
AI-generated summary
Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, died from acute myocardial infarction. The coroner found the quality of medical care in custody was high, with appropriate cardiac and diabetes care plans, regular hospital consultations (40 visits to Royal Perth Hospital), and competent nursing. However, systemic failures occurred: family were not notified when the deceased was transferred to hospital emergently, and Phase 2 terminal illness classification was not disclosed to the prisoner or family until the royal prerogative consultation process. The coroner found the deceased's allegations of mistreatment largely unsupported by contemporaneous medical records. Medical management was appropriate for his terminal condition; little could have been done to prevent death given advanced coronary atherosclerosis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
coronary angiogramcardiac monitoringcardiac resuscitationcataract surgery
Contributing factors
Severe coronary artery atherosclerosis with widespread stenosis
Longstanding insulin-dependent diabetes mellitus
Hypertension
Chronic renal failure
Advanced age
Systemic failure to notify next of kin of emergency hospital transfer
Coroner's recommendations
The Department of Corrective Services and WA Police should implement a procedure to ensure families of deceased prisoners are notified without delay notwithstanding that a person nominated as next of kin is not able to be contacted, including having alternative contact persons.
The Department of Corrective Services should consider amending Policy Directive 8 to require that a person classified as having Phase 1 or Phase 2 terminal illness be notified of the classification and its ramifications as soon as practicable after classification occurs.
The Department should consider reviewing the procedure under Policy Directive 8 to reduce instances where restraints are applied in clearly inappropriate situations, such as when a seriously ill prisoner is being transferred to hospital.
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